Pathology/Lab Coding Alert

Question: We have a clinician who orders HbA1C testing every month for every diabetes patient. Sometimes we get denials and sometimes we don’t. What could be the difference?

Georgia Subscriber

Answer: You may be running afoul of coverage rules for how frequently the Hemoglobin A1c (HbA1c) is considered medically necessary for diabetic patients.

Although most payers consider the test medically necessary to determine long-term metabolic control of blood-sugar levels for diabetic patients, how frequently payers cover the test depends on specific clinical circumstances.

CMS has a National Coverage Determination (NCD) for Glycated Hemoglobin/Glycated Protein, also known as HbA1c. Many other payers have similar rules in place for the test. The code for the lab test (not the home monitoring) is 83036 (Hemoglobin; glycosylated (A1C)).

For diabetic patients with long-term stable glucose control, testing is covered once every three months. For patients with a recent change in diabetes regimen or extenuating medical conditions such as pregnancy or recent surgery, payers may consider more frequent HbA1c testing reasonable and necessary.

For instance: The NCD states, “It may be reasonable and necessary to monitor glycated protein monthly in pregnant diabetic women.”